Parsons Heath Medical Practice Registration Form

16 years and over

You will be required to provide 2 forms of identification before we are able
to process your registration request
1.  Proof of identification i.e. Passport/Driving Licence/Birth certificate/Marriage certificate
2.  Proof of address (less than 3 months old) i.e. Utility bill/Bank or Building Society statement/Local Authority rent card/Letter from Benefits Agency/Papers from Home Office/P45
Surname: / Forename(s):
Title:
Marital Status: / Previous Surname (s):
Date of Birth: / Sex: Male / Female
Current Address:
Postcode : / Home Tel No:
Mobile Tel No:
Work Tel No:
Consent to be contacted by text message: YES/NO
E-mail address:
Consent to contact by e-mail: YES/NO
Town of birth:
Country of birth:
If from abroad date first came to UK: / Previous Address:
Postcode:
First language spoken: (please state)
Do you speak English: YES/NO
Do you require an Interpreter: YES/NO / Ethnic Origin: (please state)
Next of Kin/Emergency contact details:
Name:
Telephone No:
Relationship:
Consent to share medical information: YES/NO / Do you have a Carer: YES/NO (if YES please give details)
Name:
Telephone No:
Relationship:
Consent to share medical information: YES/NO
Height: / Weight:
Alcohol consumption:
Teetotal: YES/NO
If NO how much do you drink per week:
Pints:
Glasses of wine:
Measures of spirits: / Smoking:
Have you ever smoked: YES/NO
If YES how many per day:
Cigarettes/Cigars (please delete as appropriate)
Are you smoking now: YES/NO
If YES how many per day:
Cigarettes/Cigars (please delete as appropriate)
Do you have/had any:
Chronic Diseases/Illnesses/Operations: YES/NO
If YES please give details and dates: / Are you under the care of a Hospital at present: YES/NO
If YES please give details:
Has your Father/Mother/Sister/Brother ever had:
Heart attack: YES/NO
Stroke: YES/NO
Serious illness: YES/NO (if YES please give details ) / Do you suffer from any allergies: YES/NO
if YES please give details:

*If you are taking ANY medication please complete a separate medication form.

Please include any inhalers, contraception, eye drops etc.

*On completion of this form please allow 48 working hours before requesting an appointment. If you require an emergency appointment please speak to the Receptionist.

*Please note forms can only be accepted after 2.30pm.

Online Patient Access:

The practice usesa secure system that interfaces directly with our clinical computer.Patients wishing to book appointments and view limited medical information via the secure website will need to obtain a User ID andPINfrom the Practice. If you would like to sign up for this service please speak to one of the Reception team, you must allow a minimum of 2 weeks following your registration before requesting this.

If you wish to order your repeat prescription on line please do this via our website www.parsonsheath.co.uk

FOR OFFICE USE ONLY

Registrations documents taken in and checked by:

Proof of identification type seen:

Proof of Address type seen:

Date:

Feb 2015